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General NPI Number Information
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NPI Number | 1285429654
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Entity Type | Individual
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Provider Name | JENNIE D PHOUTHAVONG
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Gender | Female
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Dates
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Enumeration Date | 04/14/2025
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Last Update Date | 04/14/2025
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Provider Practice Location Address
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Address Line | 300 LANTERN CREST WAY
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City | SANTEE
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State | CA
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Zip | 92071-4775
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Country | US
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Telephone | 619-312-0929
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Fax |
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Provider Business Mailing Address
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Address Line | 13063 WIMBERLY SQ UNIT 115
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City | SAN DIEGO
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State | CA
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Zip | 92128-6023
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Country | US
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Telephone | 619-994-3220
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA48583
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License Number State | CA
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